What is the clinical significance of Holman's sign in relation to aortic regurgitation?

Holman's Sign in Aortic Regurgitation

Holman's sign, characterized by holodiastolic flow reversal in the proximal abdominal aorta, is a key diagnostic indicator of severe aortic regurgitation and has significant clinical implications for disease severity assessment and management decisions. 1

Definition and Diagnostic Significance

• Holman's sign refers to holodiastolic flow reversal in the proximal abdominal aorta detected on echocardiography, indicating retrograde blood flow from the aorta into the left ventricle during diastole 1
• This sign is one of the established markers of severe aortic regurgitation (AR) according to multiple clinical practice guidelines 1
• The presence of this sign helps differentiate severe AR from mild or moderate AR, as it indicates a significant regurgitant volume 1

Clinical Significance in Severity Assessment

• Holman's sign is part of a multi-parametric approach to assess AR severity, alongside other echocardiographic parameters including:

  • Vena contracta width >0.6 cm 1
  • Regurgitant volume ≥60 mL/beat 1
  • Regurgitant fraction ≥50% 1
  • Effective regurgitant orifice area (EROA) ≥0.3 cm² 1

• The presence of Holman's sign helps clinicians identify patients who may require closer monitoring or intervention, as severe AR is associated with significant morbidity and mortality 2

Implications for Patient Management

• Detection of Holman's sign should prompt comprehensive assessment of left ventricular size and function, as severe AR leads to progressive LV dilation and potential systolic dysfunction 1
• In patients with severe AR indicated by Holman's sign and other parameters:
  • Asymptomatic patients with normal LV function require surveillance echocardiography every 6-12 months 1
  • If LV dilation or dysfunction develops, surgical intervention should be considered before ejection fraction falls below 55% 1, 3
  • Symptomatic patients with severe AR should be referred for surgical intervention regardless of LV function 1

Differential Diagnostic Value

• Holman's sign helps distinguish acute from chronic AR:

  • In acute AR, the sign may be present despite normal or only mildly increased LV dimensions due to lack of time for cardiac adaptation 1
  • In chronic AR, the sign is typically accompanied by LV dilation and other compensatory changes 1, 3

• The sign is particularly valuable in clinical scenarios where other parameters may be difficult to assess, such as in patients with eccentric jets or poor acoustic windows 1

Prognostic Significance

• The presence of Holman's sign correlates with worse outcomes in AR patients:
  • Higher risk of heart failure development 2
  • Increased likelihood of requiring aortic valve surgery 2
  • Greater overall mortality risk, with 10-year mortality rates of approximately 34% in patients with severe AR 2

Pitfalls and Caveats

• Holman's sign should not be used in isolation for AR severity assessment but as part of a comprehensive evaluation 1
• Technical factors can affect detection:
  • Suboptimal Doppler alignment may lead to underestimation of flow reversal 1
  • Respiratory variations can affect measurements 1
• In patients with aortic dissection and concomitant AR, Holman's sign may be present due to the AR component, requiring careful differentiation of the primary pathology 1
• The sign may be less reliable in patients with significant aortic atherosclerosis or tortuosity 1

Relation to Acute Aortic Syndromes

• In the context of acute aortic syndromes, the presence of Holman's sign may indicate aortic regurgitation as a complication of aortic dissection 1
• When AR is detected in the setting of suspected aortic dissection, immediate surgical intervention is typically required, as this represents a surgical emergency 1
• Intra-aortic balloon counterpulsation is contraindicated in patients with acute severe AR showing Holman's sign 1